Citation Nr: 18155262 Decision Date: 12/03/18 Archive Date: 12/03/18 DOCKET NO. 13-07 738 DATE: December 3, 2018 REMANDED The issue of entitlement to service connection for a disability manifested by left shoulder pain is remanded. The issue of entitlement to service connection for a disability manifested by right shoulder pain is remanded. The issue of entitlement to service connection for a disability manifested by left wrist pain, to include as secondary to right navicular fracture, is remanded. The issue of entitlement to service connection for a disability manifested by low back pain is remanded. The issue of entitlement to service connection for a disability manifested by left knee pain is remanded. The issue of entitlement to service connection for a disability manifested by right knee pain is remanded. The issue of entitlement to service connection for a disability manifested by left ankle pain is remanded. The issue of entitlement to service connection for a disability manifested by right ankle pain remanded. The issue of entitlement to service connection for an acquired psychiatric disorder remanded. REASONS FOR REMAND The Veteran served on active duty from March 1984 to March 1988. These matters come before the Board of Veterans’ Appeals (Board) on appeal from a December 2011 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO). The Veteran filed a notice of disagreement in December 2011 and was provided with a statement of the case in February 2013. The Veteran perfected his appeal with a February 2013 VA Form 9. The Veteran testified before the undersigned Veterans Law Judge in November 2017; a transcript is of record. These matters were previously before the Board in March 2018, at which time they were remanded for further development of the record. Entitlement to service connection for right and left shoulder disabilities; right and left knee disabilities; and a low back disability The Veteran contends that he has disabilities manifested by right and left shoulder pain, right and left knee pain, and low back pain as a result of being hit by a crane in-service. Service treatment records do not expressly document the injury, nor do they reflect complaints/treatment/diagnoses relating to the shoulders, knees or low back. However, service dental records are consistent with the Veteran’s testimony of sustaining trauma to his two front teeth at the time of the claimed injury (“I was a signalman, the crane operator was in training, and the boom knocked me out, hitting me directly in the face and knocking my two front teeth out…I was in pain everywhere.”). See Hearing Transcript, p. 6; see also August 1985 Service Dental Records (reflecting trauma to teeth #8 and #9). Current VA treatment records reflect ongoing complaints of, and treatment for bilateral shoulder pain, bilateral knee pain, and lumbar pain. But see October 2013 VA Treatment Record (noting chronic pain, lumbar spine, knees and shoulders likely due to degenerative process, considering also fibromyalgia as contributing factor). The Board notes the holding in the recent Federal Court decision of Saunders v. Wilkie, 886 F.3d 1356 (2018), which requires the RO to schedule the Veteran for VA examinations to determine whether his bilateral shoulder pain, bilateral knee pain, and/or low back pain result in functional impairment such that they may qualify as a disability in the event an underlying diagnosis, is not provided. The Veteran should thus be scheduled for such an examination(s) on remand. The Veteran also testified, and VA treatment likewise records reflect, that he receives ongoing private medical treatment for his various joint/musculoskeletal symptoms. In November 2017, the Veteran submitted a VA form 21-4142a General Release for Medical Provider Information identifying City Heights Family Medical Center. The RO did not attempt to obtain these records. In March 2018, the Board directed the RO to obtain the records from City Heights Family Medical Center and any other private treatment identified by the Veteran. Unfortunately, the April 2018 and May 2018 letters requesting this information were returned to VA as “undeliverable.” Notably, the April/May 2018 letters were sent to a different mailing address than the June 2018 SSOC which was not returned as undeliverable. It thus appears that the Veteran’s address has changed. On remand, steps should be taken to confirm and correct, if necessary, the Veteran’s mailing address, and to afford him another opportunity to submit the requested information. Lastly, VA treatment records indicate that the Veteran has applied for disability benefits from the Social Security Administration (SSA). As such, a remand is necessary to obtain any determination pertinent to the Veteran’s claim for SSA benefits, as well as any medical records relied upon concerning that claim. Entitlement to service connection for bilateral ankle disabilities The Veteran contends he has disabilities manifested by right and left ankle pain as a result of service. Service treatment records reflect treatment for various soft tissue and trauma/sports-related injuries to the ankles. Current VA treatment records show ongoing complaints of right and left ankle pain. In a letter received in October 2017, a VA physician opined that the Veteran’s joint/ankle pain was more likely than not related to military service. No rationale was provided. In light of the foregoing, and especially considering the holding in Saunders, the Board finds that the Veteran should be afforded the appropriate VA examination on remand. See Saunders, supra. Entitlement to service connection for an acquired psychiatric disorder The Veteran contends that he has an acquired psychiatric disorder as a result of being hit by a crane in-service. As noted, service dental records are consistent with the Veteran’s testimony of sustaining trauma to his two front teeth at the time of the claimed injury (“I was a signalman, the crane operator was in training, and the boom knocked me out, hitting me directly in the face and knocking my two front teeth out.”). See Hearing Transcript, p. 6; see also August 1985 Service Dental Records (reflecting trauma to teeth #8 and #9). Moreover, STRs confirm treatment for stress-related fatigue. Current VA treatment records reflect various psychiatric diagnoses, including major depressive disorder and anxiety. To date, the Veteran has not been afforded a VA examination to determine the nature and etiology of his claimed acquired psychiatric disorder. In light of the STRs, the Veteran’s competent testimony as to onset, and the current psychiatric diagnoses, he should be afforded such an examination on remand. Entitlement to service connection for a left wrist disability The Veteran contends that his left wrist disability (claimed as left wrist pain) is secondary to his service-connect right wrist disability. Given the evidence of outstanding private treatment and SSA records, the Board finds that it would be premature to adjudicate the left wrist claim at this time. Thus, it is also remanded pending further development. The matters are REMANDED for the following action: 1. Take the steps necessary to clarify the Veteran’s current mailing address and update the record accordingly. (Note: the June 2018 SSOC, which was not returned as undeliverable, was sent to a different address than the returned April/May 2018 notification letters). 2. After confirming the Veteran’s current mailing address, re-send to the Veteran any and all correspondence that was returned and marked as undeliverable. See e.g., April 2018 and May 2018 Notification Letters. In doing so, ask the Veteran to identify the provider(s) of any and all evaluations and/or treatment that he has received for his claimed painful joints and psychiatric disorder and to provide authorizations for VA to obtain such records. Specifically ask the Veteran to provide an updated authorization and consent form to obtain treatment records from City Heights Family Medical Center. If any records are unavailable, follow the provision in 38 C.F.R. § 3.159 (e) regarding private records. 3. Obtain any outstanding records of VA treatment. 4. Contact the SSA and request the Veteran’s complete SSA records pertaining to any decision(s) on his application for SSA disability benefits, and all underlying medical records which are in SSA’s possession. All actions to obtain these records should be documented fully in the claims file. 5. Schedule the Veteran for an examination by an appropriate clinician to determine the nature and etiology of any diagnosed disorder(s) or functional limitation(s) of the (i) right shoulder; (ii) left shoulder; (iii) right knee; (iv) left knee; (v) right ankle; (vi) left ankle; and (vii) low back. The examiner must opine whether it is at least as likely as not that the Veteran has a diagnosed disorder of the (i) right shoulder; (ii) left shoulder; (iii) right knee; (iv) left knee; (v) right ankle; (vi) left ankle; and/or (vii) low back or, if there is/are no diagnosed disorder(s), if he has functional limitations of his shoulder(s), knee(s), ankle(s) and low back stemming from pain. If there is either a diagnosed disorder(s) of the shoulder(s), knee(s), ankle(s) and/or low back OR functional limitations due to pain of shoulder(s), knee(s), ankle(s) and/or low back, the examiner must opine as to whether it is at least as likely as not related to an in-service injury, event, or disease, including the reported in-service crane accident, or, with respect to the ankles, the documented bilateral ankle injuries/trauma in-service. The examiner is advised that the Veteran is competent to report symptoms, treatment, and injuries, and that his reports must be taken into account in formulating the requested opinions. In this regard, service dental records are consistent with the Veteran’s testimony of sustaining trauma to his two front teeth at the time of the claimed crane injury (“I was a signalman, the crane operator was in training, and the boom knocked me out, hitting me directly in the face and knocking my two front teeth out…I was in pain everywhere.”). See Hearing Transcript, p. 6; see also August 1985 Service Dental Records (reflecting trauma to teeth #8 and #9). Complete rationale must be provided for any opinion given. 6. Schedule the Veteran for an examination by an appropriate clinician to determine the nature and etiology of any diagnosed acquired psychiatric disorder, to include depression and anxiety. The examiner must opine whether any current psychiatric disorder is at least as likely as not related to an in-service injury, event, or disease, including the Veteran’s reports of being hit by a crane in-service and/or documented treatment for stress-related fatigue in-service. The examiner is advised that the Veteran is competent to report symptoms, treatment, and injuries, and that his reports must be taken into account in formulating the requested opinions. Complete rationale must be provided for any opinion given. 7. After accomplishing any additional development deemed appropriate, readjudicate the claims on appeal. If any benefit sought in connection with the claims remains denied, the Veteran should be provided with an appropriate Supplemental Statement of the Case (SSOC), with a copy to his representative, and given the opportunity to respond. DEBORAH W. SINGLETON Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD H. Hoeft, Counsel